I tested positive in feb 07 and at the time my tcell count was 183 and viral load was 97,000. My doctor started me on atripla and on my next lab results my tcell went up to 280 and viral load to 397. the next result were also good news tcell up to 391 but the lab messed up and didn't get a viral load although my DR suggested it would seem to be undectable seeing my tcells went up. Well this last Lab result were not good at all. I just got a call from the staff at doctors office asking if i missed a dose and i said no. She informed me my viral load went way up to just over 50,000 and my tcell went down back to 280. Is there any reason why this happened did the virus find a resistance to atripla or can this be due to me having a cold a couple of weeks prior to taking my labs? I am very worried because i was doing so well and i had no side effects to atripla.

Response from Dr. Sherer

You ask a good question. It is possible that your viral infection caused a short term increase in your viral load. Unfortunately, the magnitude of the viral load increase and the associated drop in the CD4 cell count suggest a more serious problem, i.e. drug resistance.

Unfortunately, drug resistance mutations and virologic failure can occur, even in the presence of excellent adherence. While it is uncommon, occuring in <10% of people on Atripla in the first year of treatment in clinical trials, it does occur.

There are several possible answers as to why it happens. One is that your virus may have had one or more resistance mutations when you acquired it. You and your doctor can answer these questions - did you have a resistance test done before you started this regimen?
If so, was it consistent with a wild-type virus, i.e. with no significant primary resistance mutations?

Even if that were the case, your virus may still have had significant resistance mutations in a percentage of clones, i.e. < 20%, which would have escaped detection due to the sensitivity of the resistance test, but which still could have led to drug resistance and virologic failure.

Other factors that might contribute to this outcome could include other illnesses (like your 'flu') or vaccinations at the time of the last blood test, or other medications that might have interfered with the absorption or action of your ART medications. You and your doctor will need to review all of this clinical information and assess your current situation, as well as repeat the viral load and CD4 cell count and obtain a resistance test, in order to plan for the next best action in your management. Even if this IS virologic failure and drug resistance, there are second line options available to you that should achieve full viral suppression and rising CD4 cells, as you initially had with this regimen.

I urge you not to be overly discouraged and to see your doctor promptly to undergo this assessment, get these next blood tests, and figure out your next best course of action.

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